Healthcare Provider Details

I. General information

NPI: 1386005809
Provider Name (Legal Business Name): TIMOTHY GAGAN PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/10/2016
Last Update Date: 03/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

533 S FAIRFAX AVE
LOS ANGELES CA
90036-3129
US

IV. Provider business mailing address

3176 ATWATER AVE
LOS ANGELES CA
90039-2404
US

V. Phone/Fax

Practice location:
  • Phone: 323-930-4815
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number10870
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: